The Agency for Healthcare Research and Quality and the Institute of Medicine have called for the adoption of improved handoff tools and processes to address the high incidence of harmful communication failures in hospitals. Comparative effectiveness research (CER) has identified practices that improve handoff quality and patient safety, but adoption of these CER-based practices across medical centers has been slow. In a pilot study recently completed at Children's Hospital Boston, we found that introduction of a Resident Handoff Bundle (RHB) was rapidly adopted by residents and was associated with a 43% reduction in detected medical errors. We now seek to implement the RHB in eight major pediatric residency programs. The RHB includes three major elements:1) TeamSTEPPS training, an evidence-based teamwork, leadership, and communications training program developed by AHRQ and the Department of Defense;2) Introduction of standardized verbal protocols and mnemonics, which have been associated with improved handoff quality and reduce medical errors;and 3) Introduction of standardized written/computerized handoff tools, which have been shown to improve handoff quality and have been associated with reduced rates of adverse events. We will apply intensive state-of-the-art prospective safety surveillance methodologies, direct observation, and time motion analysis, each of which we have used in prior studies, to assess the effectiveness of the RHB. We will additionally seek to determine the manner in which the RHB's adoption and impact is modified by a) hospital-level factors, including the presence of a robust computer system and attending physician supervision of sign-out;and b) patient-level factors, especially the presence of a chronic disease that conveys functional limitations or disability, a priority condition. To assist with dissemination throughout the PRIS network, the IIPE, and beyond, we will develop a toolkit that will provide a summary of our findings and will describe the fundamental building blocks of a successful handoff program. We hypothesize that by bundling CER-based handoff interventions together and disseminating them through a research and education network, we will accelerate adoption of evidence based handoff practices which will ultimately result in significant reductions in medical errors, verbal and written miscommunications, and improved physician satisfaction and workflow in hospitals nationwide. PUBLIC HEALTH RELEVANCE: Adoption of proven communication strategies has been shown to decrease the risk of miscommunications in hospitals and improve patient safety. We propose to study the effect of implementing a Resident Handoff Bundle (RHB) that will include teamwork training for residents, verbal handoff strategies, and a written or computerized handoff tool in eight major medical centers. We will rigorously measure the effects of the RHB on patient safety and care processes, and will study how hospital factors (e.g. presence of sophisticated computer systems) and patient factors (e.g. presence of a complex chronic disease) affect adoption across sites.